Headache Flashcards
HA
Primary vs Secondary
Primary: Migraine (with or without aura), Tension, Cluster
-No known underlying cause
-90% of headaches are benign primary type
Secondary Headache: Brain tumors, aneurysms
-Symptoms of underlying disorder
Migraine
general
Common disorder
Women > Men
Boys < Girls (< 12yo more often seen in boys) -Increased with age, Abdominal migraines
Age 30-39
Though possible from child to elderly
Very old and very young uncommon
Familial/genetic component
Major cause of disability worldwide
Migraine
patho
Still developing theory
Genetic component – hyperexcited neurovascular system
Cortical spreading depression
Trigeminal nerve activation
Intracerebral vasodilation component
Migraine
S/Sx
Episodic disorder
Lasting minutes to days
Unilateral, usually
Retro-orbital
Pulsating
Photophobia / Phonophobia
Associated with nausea and vomiting
May be associated with aura
No persistent, hard neurological findings
Migraines classifications
Classic vs common
Migraine with aura (classic migraine)
Less common
Migraine without aura (common migraine)
More common by 5:1
migraine
prodome
Yawning, euphoria, fatigue/depression, irritably, food cravings
Migraine
Aura
Aura is defined as a focal visual, sensory, or motor neurologic disturbance with a developing headache
Can include bright lines, shapes, tinnitus, noises, paresthesia, loss of vision, hearing, feeling or ability to move a part of the body
Increases in intensity over one to several hours, often unilateral, throbbing or pulsatile in quality
Common to report photophobia, phonophobia and cutaneous allodynia (perception of pain caused by normal activities i.e., wearing glasses)
Associated with ~25% of migraines (classic migraine)
Migarine
headache
Usually Unilateral throbbing, nausea, vomiting, photophobia, phonophobia
migraine
Scintillating scotoma
Scintillating scotoma – Aura spots that flicker between light and dark
HA
PE to do’s
Obtain blood pressure and pulse
Listen for bruits for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles
The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests.
Gait examination should include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and Romberg test.
Migraines
Dx
clinical
Migraine
criteria (w/o aura)
●(A) At least five attacks fulfilling criteria B through D
●(B) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
●(C) Headache has at least two of the following characteristics:
*Unilateral location
*Pulsating quality
*Moderate or severe pain intensity
*Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
●(D) During headache, at least one of the following:
*Nausea, vomiting, or both
*Photophobia and phonophobia
●(E) Not better accounted for by another ICHD-3 diagnosis
criteria for migraine with aura
● At least two attacks fulfilling criterion B and C
● One or more of the following fully reversible aura symptoms:
*Visual
*Sensory
*Speech and/or language
*Motor
*Brainstem
*Retinal
●(C) At least three of the following six characteristics:
*At least one aura symptom spreads gradually over ≥5 minutes
*Two or more symptoms occur in succession
*Each individual aura symptom lasts 5 to 60 minutes
*At least one aura symptom is unilateral
*At least one aura symptom is positive
*The aura is accompanied, or followed within 60 minutes, by headache
●(D) Not better accounted for by another ICHD-3 diagnosis
migraine
abortive Tx
- Nonpharmacologic/avoidance of triggers
-
NSAID & APAP
Ketorolac -
Triptans
Sumatriptan (Imitrex)
Rizatriptan (Maxalt) - Ergotamine
- Dopamine antagonist & Diphenhydramine
Metoclopramide (Reglan)
Prochlorperazine
Chlorpromazine (Thorazine) - Steroids
- Fluids
- Opioids
migraine
preventative medications
Topiramate (Topamax)
Valproate (Depakote)
Propranolol (Inderal)
Non-pharmacological/avoidance of triggers
Migraine
Special population Tx
Pregnant
Avoid ergotamine & NSAIDs
Antiepileptics NOT approved for migraine use
ACOG recommends Reglan (B) and Acetaminophen
< 12 yo – pediatric population considerations
Avoid Triptans
NSAIDs & APAP
Promethazine (Phenergan)
Propranolol for preventative
Tension headache
general
Most common type of headache
Bilateral, band or vice like
Pericranial muscle involvement
Nuchal rigidity?
No hard neurological findings
Tension HA
Classifications based on frequency
Infrequent episodic
< 1 per month
Frequent episodic
1-14 per month
Chronic
> 14 per month
Tension HA
EPI
- Most common type of primary headache
- Universal, 86% of 12-41yo
W > M, slightly - 2-3 times more common in kids as opposed to migraines
Increases with age and is also higher in female kids
Presentation similar to adults - Most people can identify a cause:
Stress, fatigue, eye strain, myalgias, mild viral infections
Tension HA
features
Mild to moderate pain
Non-throbbing
Dull, pressure, band, tight hat
Pericranial muscle tenderness
No other associated features
tension
Dx
clinical
At least two of following:
Bilateral
Pressing or tight quality
Mild to moderate intensity
Not aggravated by routine physical activity
And, both of following:
No nausea or vomiting
No more than one of photophobia or phonophobia
Tension HA
acute Tx
NSAIDs & Acetaminophen
Ibuprofen, ketorolac, naproxen
Most common options for pediatric patients
Combination meds
Butalbital, APAP, Caffeine (Fioricet)
Migraine medications
Muscle relaxants (mixed data)
Opioids
Nonpharmacologic/avoidance of triggers
Tension HA
Chronic Tx
NSAID
Amitriptyline
Nortriptyline
Fluoxetine -SSRI
Muscle relaxant
Nonpharmacologic:
Physical therapy
Acupuncture
Avoidance of triggers
Cluster HA
S/Sx
Unilateral
Non-pulsatile
EXTREME though brief episodes of pain in clusters of hours to days
Conjunctival injection
Rhinorrhea
Lacrimation
Facial swelling
Horner’s syndrome
Cluster headache
Epidemiology
Rare < 1% of population
Male > Female, 4:1
Typically, 20-40 age range
Genetic link
Smoking
Horner’s Syndrome
Miosis – constricted pupil
Ptosis – drooping of upper eye lid
Anhidrosis– absence of sweating on the face
Enophthalmos – sinking of eye into bony cavity
Cluster HA
Dx
A sense of restlessness or agitation
Attacks have a frequency between one every other day and eight per day; during part (but less than half) of the active time-course of cluster headache, attacks may be less frequent
●At least five attacks
●Attacks characterized by severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes when untreated; during part (but less than half) of the time-course of cluster headache, attacks may be less severe and/or of shorter or longer duration
●Either or both of the following:
*At least one of the following symptoms or signs ipsilateral to the headache:
-Conjunctival injection and/or lacrimation
-Nasal congestion and/or rhinorrhea
-Eyelid edema
-Forehead and facial sweating
-Miosis and/or ptosis
Cluster HA
Acute Tx
High flow oxygen first
Subcutaneous Sumatriptan if no response
Intranasal lidocaine as alternative treatment
Cluster
Preventative
Verapamil and/or Steroids
Home O2
Avoidance of triggers
HA
red flags
Causes of thunderclap headache
Lumbar puncture
After the CT
Still needs to be done if your index of suspicion is high for SAH
Confirm for presence of RBCs and xanthochromia (bili) in CSF
Most sensitive 12 hours after SAH
Gives information regarding pressure, bleeding, infection
‘Other’ headaches
Temporal arteritis/Giant cell arteritis
Cervical artery dissection
Abdominal migraine
Basilar / vestibular migraine
Ocular migraine
Trigeminal neuralgia
Occipital neuralgia
Venous sinus thrombosis
CO poisoning
Intracranial Mass
Post-traumatic (covered later)
Meningitis (covered later)
Temporal Arteritis/Giant cell arteritis
general
Pathology
Inflammation of large to medium vessels
Remodeling can lead to vessel occlusion
Epidemiology
Age >50, Caucasian / Scandinavian, W>M
giant cell arteritis
S/Sx
Symptoms
HA, scalp tenderness, temporal pain, jaw claudication, fever, amaurosis fugax (temp loss of vision)
giant cell arteritis
Dx and Tx
Diagnosis
History and exam
ESR >50, CRP less sensitive
Biopsy
Treatment
Prednisone IV or PO, high dose
Immunosuppressive drugs
GCA Headache
HA usually throbbing and continuous.
Focal tenderness on direct palpation typically present. Patient may note scalp tenderness with hair combing, or with wearing a hat or eyeglasses.
GCA
Jaw claudication
Jaw claudication: fatigue or discomfort of the jaw muscles during chewing of firm foods or prolonged speaking.
Result of ischemia of maxillary artery supplying masseter muscles.
Highly predictive of temporal arteritis
GCA
Vision
Around 50% experience visual symptoms
Initial visual symptoms may be transient and intermittent, typically unilateral visual blurring or vision loss.
Vision loss may not be reversible if treatment with steroids isn’t started immediately within the first few days
GCA
polymyalgia rheumatica
About50% of patientswith GCA have underlying polymyalgia rheumatica (pain and stiffness of the shoulder and hip girdle)
About 15% with polymyalgia rheumatica develop GCA
GCA
Tx
Steroids early to avoid permanent vision loss
High dosing of oral prednisone
Monitored for side effects
Cervical artery dissection
general
patho and epi
Pathology
Separation of layers of the vessel
Major cause of morbidity is thrombi -> stroke
Epidemiology
Young
Associated with minor trauma, spontaneous, connective tissue disease
Cervical artery dissection
Sx
HA progressive vs thunderclap, neck pain, ischemic changes
Cervical artery dissection
Dx and Tx
Diagnosis: CTA, MRA
Treatment: Anticoagulation
Migraine variants
Hemiplegic migraine
Unilateral weakness with migraine with aura attack
Migraine variant
Abdominal migraine
Abdominal pain is primary complaint
Same triggers as migraines
migraine variant
Vestibular migraine and Ocular migraine
Vestibular migraine
Vertigo associated with headache
Ocular migraine
Transient vison loss
Occipital neuralgia
general
patho and Sx
Pathology
Entrapment of occipital nerve by scalp and neck muscle
Symptoms
Brief episodes of pain electric like pain in Occipital nerve distribution
Allodynia, can lead to occipital constant headache
Occipital neuralgia
Dx and Tx
Diagnosis
Clinical, may consider CT / MRI
Treatment
Occipital nerve block
Carbamazepine
Gabapentin
Venous sinus thrombosis
General
Patho and Epi
Pathology
DVT of brain
Leads to ischemic changes, disruption of BBB
Epidemiology
W>M, pregnancy, thrombophilia
Venous sinus thrombosis
Sx
Headache, nausea, vomiting, seizure, drowsy
Venous sinus thrombosis
Dx and Tx
Diagnosis: MRV, D-dimer, thrombophilia screen
Treatment: Anticoagulation, endovascular
Carbon monoxide poisoning
Intracranial Mass
Epi
Occurs during course of disease within 40-60% of patients
MC masses include gliomas, meningiomas, and pituitary adenomas
intracranial mass
Sx
Vary widely due to size and location of mass
Nausea and vomiting may be seen
Moreso tension-type headache
Red flags in history such as fever, neurologic signs, over age 50, etc.
intrcranial mass
Dx and Tx
Diagnosis
MRI exceeds CT imaging for tumors
Treatment
Depends on tumor type, status of patient, and extent of disease
Early – glucocorticoids and simple analgesics
